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Scientific community leads HTA development

Country: 
Estonia
Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
(14) 2009
Author(s): 
Ain Aaviskoo, Janek Saluse, Eva Palm
Health Policy Issues: 
New Technology, Funding / Pooling, Benefit Basket
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Abstract

In Estonia there is no formal system of health technology assessment that bases on international experiences. Assessment of new services to be included in the publicly funded benefit package is partly regulated by the Health Insurance Act and respective government regulation. Actual evaluation is done with varying quality and methodology. Hence, research and public policy institutions have initiated a process of developing capacity and formalizing HTA in Estonia.

Purpose of health policy or idea

In Estonia there is no formal system of health technology assessment that bases on international experiences. Assessment of new services to be included in the publicly funded benefit package is partly regulated by the Health Insurance Act and respective government regulation. Actual evaluation is done with varying quality and methodology. Hence, research and public policy institutions have initiated a process of developing capacity and formalizing HTA in Estonia.

The goal is both to increase the capacity of health economics and improve the role of economic decision-making in health policy in Estonia. The practical purpose is to create conditions for an institution with formal responsibilities and capacity to carry out HTA analysis. It is intended that such an institution should work in close collaboration with the Estonia Health Insurance Fund (EHIF), but remain independent to maintain an unbiased approach and image.

Main points

Main objectives

  • To create formal and practical conditions (legal foundation, competence and financing) for HTA in Estonia.
  • To synchronize HTA activities with other countries for efficiency purposes, but also for comparison of the results.
  • Additional goals are developing the quality and quantity of health economics competence and integrate HTA systematically into public health policy assessments.

Type of incentives

Currently the main incentive is probably financial support from EEA/Norway financial grant for epidemiology and public health education and research. Research institutions are often asked to support policy decisions by creating evidence and sound suggestions, which is to be turned from an ad hoc to a systemic approach.

Groups affected

Patients, hospitals, doctors, Ministry of Social Affairs, Estonian Health Insurance Fund, health economists.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-neutral system-neutral

Political and economic background

Currently health technologies are assessed with varying quality and methodology in Estonia. For example, before a new health service is added to the positive list of health services reimbursed from public funds, it must be accessed through a process led by the Estonian Health Insurance Fund (EHIF). However, the assessment is prepared by the organization which submits the proposal of the new service to be included in the reimbursement list. The capacity to prepare true HTA is questionable.

The State Agency of Medicines has strict rules for the assessment of clinical effectiveness of medicines that are allowed to the market. Economic assessment is usually done by EHIF, but the system is not transparent. Few academic studies and sporadic evaluation studies have been undertaken to assess national public health programs.

All these assessments are conducted by different institutions or persons according to their specific purposes. There is no unitary system or purpose and therefore there is a need to establish a central organization which would organize that assessments occur after fixed intervals and follow the same principles. It is also important to note that postgraduate level public health training has not focused on health economics so far in Estonia.

Due to the critical economic situation in Estonia, the private and public sector have had to reduce costs, a situation that will probably not change in the nearest future. Furthermore, the Estonian health system is known for its orientation towards efficiency by spending just about 5% of national GDP on health. Thus, because of the decreasing income the government is facing ever more difficult choices in deciding about the efficient use of public resources.  Therefore it is acknowledged that paying more attention to economic assessment in the health sector is a must to separate less and more cost-effective technologies. It also makes it possible to discover alternative and more cost-effective solutions for preventable costs. Altogether the need for a central organization for HTA is getting more and more noticeable.

According to the Health Insurance Act, the main criteria of including a healthcare service into the healthcare services list is its cost-efficiency. It is regulated by the act about health government regulation on "The criteria for changes in the EHIF list of healthcare services and the conditions and organization  for their assessment". This act stipulates that when a healthcare service is assessed, the results are to be compared with the services already included in the list or with other alternative services solving the same medical problem according to the following criteria:

  1. costs of service (price);
  2. costs per patient;
  3. costs of drugs with price abatements;
  4. costs of compensation of temporary incapacity for work;
  5. costs of potential compensatory allowance;
  6. costs of restoring the patient`s capability for work and impact on income.

Since January 2009, the EHIF has published guidelines for economical assessment of Estonia Health Insurance Fund services. The purpose of these guidelines is to give technical guidance for introducing changes to the healthcare services list, using transparent principles. These guidelines include the relevance of the price of the service, cost-effectiveness and a prediction about its impact on health insurance costs.

Additionally, EHIF has developed a regulation for pharmacoeconomic analysis that uses information from all three Baltic States (Latvia, Lithuania and Estonia). The three countries have decided to use pharmacoeconomic analysis as a basis for their drug reimbursement and other state funding decisions.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Origins of health policy idea

The Ministry of Social Affairs and  the Estonian Health Insurance Fund (EHIF) should be mainly interested in HTA to understand what kind of technologies they should finance. In the long run, HTA should improve the quality, efficiency and accessibility of health services, leading to better health conditions for patients. Patients and doctors can also use this information to understand why different technologies are financed variously and how to gain the long-time goals. The solid and wide accepted assessment system enables Estonia to use experiences from other countries (data, models etc) and to compare the results between Estonia and other countries.

As a start, the Department of Public Health of the University of Tartu has participated and is participating in several international health technology assessment projects in conjunction with international organizations likes EUnetHTA, NICE, FinOHTA etc. The public policy think-tank "Praxis Centre for Policy Research" has conducted several assessments of national public health programs.

As an additional benefit it can be foreseen that, once decision makers get used to methodologically robust HTAs and especially when these occur regularly, these analyses will get a stronger impact on their decision.

It is important to mention that no formal initiative by the Ministry of Social Affairs has been taken to foster the development of HTA in Estonia.

Initiators of idea/main actors

  • Government: The Ministry of Social Affairs has not objected to the initiative, but due to serious financial and organizational reasons it is not to contribute substantially to the project.
  • Providers: For doctors (and other health professionals) this kind of new organization and analysis is yet seen as an academic exercise. However, as the practice of submitting proposals for new services to EHIF is getting more frequent, professionals (professional organizations) and health providers have understood the power of sound economic justification.
  • Payers: EHIF supports the idea strongly. However, their primary intention is to develop EHIF?s own capacity for HTA.
  • Patients, Consumers: Patients (patient organizations) historically have been supporting the approach towards a prudent use of public resources.
  • Scientific Community: Academic institutions see an opportunity for more evidence-based policy making, as well as improving their technical skills in a neglected area.

Approach of idea

The approach of the idea is described as:
new: By today, the first steps to solve this problem have been made and a plan has been developed how to continue with HTA. The Department of Public Health of the University of Tartu and Praxis, in conjunction with EHIF, have started regular collaboration

Stakeholder positions

It is not easy to decide on the appropriate position for such an independent but powerful body. So far EHIF has been considered the main source of economic assessment for health care in Estonia. EHIF has the legal responsibility to be fiscally sustainable, it has a sound central organization and an understanding of economic reasoning when it comes to resource allocation in health care. However, so far EHIF's financial projections have been made on 4 year basis only and capacity as well as skills for more sophisticated econometric analysis does not exist yet. Furthermore, EHIF's current position as the single most powerful purchaser of healthcare services in Estonia is probably not the best platform for an independent HTA agency, which would be accepted by all stakeholders in the Estonian health domain.

On the other hand, establishing a new separate organization is questionable due to diminishing resources within the health sector in the coming years. Also, it is not an easy concept for doctors to accept monetary values for life and treatment methods. Long conceptual debates can therefore be expected and could be further exacerbated by a fierce fight for money in the aftermath of the economic crisis.

For the academic community the main obstacle is the so far poor competence in this field in Estonia.

Most probably, the current approach, which is led by academic and research organizations, will result on the one hand in increased activity of HTA and on the other hand in pressure by stakeholders for a rational basis for decision making either for limiting services or increasing financing.

Leadership by the research community is not a usual way of creating policy change. Therefore the success probably needs some serious pressure by one or another stakeholder group. Thus, the role of the research community is to raise awareness and bring the capacity to a critical level.

Actors and positions

Description of actors and their positions
Government
Minitry of Social Affairsvery supportiveneutral strongly opposed
Providers
Doctorsvery supportiveneutral strongly opposed
Payers
EHIFvery supportivevery supportive strongly opposed
Patients, Consumers
Patientsvery supportiveneutral strongly opposed
Scientific Community
Academic institutionsvery supportivesupportive strongly opposed

Influences in policy making and legislation

The idea of educating competence and establishing a HTA organization in Estonia has yet not led to any changes in legislation and probably will not in the nearest future. The current technical process seems to satisfy the basic needs. 

Actors and influence

Description of actors and their influence

Government
Minitry of Social Affairsvery strongstrong none
Providers
Doctorsvery strongneutral none
Payers
EHIFvery strongstrong none
Patients, Consumers
Patientsvery strongweak none
Scientific Community
Academic institutionsvery strongstrong none
EHIFAcademic institutionsPatientsDoctorsMinitry of Social Affairs

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Expected outcome

Most probably it is inevitable that HTA will find its place in healthcare decision-making in Estonia. As mentioned before - public policies in Estonia generally favour an efficiency-oriented approach. The current political leadership has already taken radical steps in cutting back public spending during the financial crisis to maintain fiscal balance (see report 13/2009). The quest for more efficiency in the health system, which is seconded by increased individual responsibility, has been publicly stated as the main policy goal.

An 18% annual budget increase during the last 4 years in the healthcare budget has prevented EHIF from making real choices. Further decisions are much more difficult and therefore will need good explanation. This forms a solid basis for developing systematic and comprehensive action in the health technology assessment field. Financing of the HTA itself remains probably the biggest obstacle.

Impact of this policy

Quality of Health Care Services marginal fundamental fundamental
Cost Efficiency very low very high very high

References

Sources of Information

Ravikindlustuse seadus. Elektrooniline Riigi Teataja.https://www.riigiteataja.ee/ert/act.jsp ? id= 833234

Eesti haigekassa tervishoiuteenuste loetelu muutmise kriteeriumid ning nende hindamise tingimused ja kord. Elektrooniline Riigi Teataja.  http://www.riigiteataja.ee/ert/act.jsp?id =834210

Tervishoiuteenustele tervishoiuökonoomilise hinnagu andmise juhend. Versioon 1. 2. Jaanuar 2009

Ravimite farmakoökonoomiline hindamine. Eesti haigekassa. http://www.haigekassa.ee/kindlustatule/soodusravimid/hindamine

Author/s and/or contributors to this survey

Ain Aaviskoo, Janek Saluse, Eva Palm

Suggested citation for this online article

Aaviskoo, Ain, Janek Saluse, and Eva Palm. "Scientific community leads HTA development". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/ee/a14/2